Taconic Rehabilitation and Nursing at Ulster

Inspectors wroteREVISED 6/10/2025 IIDR Based on observation, record review, and interview conducted during the recertification survey from 3/5/2025 through 3/12/2025, the facility did not ensure residents received quality of care in accordance with professional standards of practice for one (1) of four (4) residents reviewed for accidents. Specifically, on 12/12/24, Resident #69 was observed ambulating to the bathroom in their room unassisted, as Certified Nurse Aide # 8 assisted the resident their legs became weak, and the resident was lowered to the floor. Certified Nurse Aide #8 left Resident #69 to seek help, upon return Resident #69 was found in a different position, complained of pain to the right side of lower back, and sustained a hematoma (bruise) to the face. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 3/5/2025 to 3/12/2025, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was evident for 1 of 1 residents (Resident #65) reviewed for Dignity. Specifically, Resident # 65 was observed ambulating wearing socks that were labeled with the resident's name on the top of the foot clearly visible to other residents, visitors and staff.

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 3/5/25-3/12/25, the facility did not ensure that they were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for Resident #30 reviewed for Call Systems/Environment. Specifically, the call system unit at the bedside for Resident #30 was not accessible.

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (NY00346725) from 3/5/25 to 3/12/25, the facility did not ensure residents and/or representatives were provided written notification in a manner they understood for 5 of 5 residents reviewed for discharge (Resident #50, #202, #203, #68, and #69) who were transferred/discharged to the hospital. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand was provided to the resident and the resident's representative(s).

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (NY00346725) from 3/5/25 to 3/12/25, the facility did not ensure residents or resident representatives were notified in writing of the facility bed hold policy for 5 of 5 residents (Resident #50, #202, #203, #68,#69) reviewed for discharge. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of facility bed hold policy was given to the resident or their representatives.

Inspectors wroteBased on observation, record review, and interview during the recertification survey from 3/5/25-3/12/25, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 (Resident #68) of 4 residents reviewed for pressure ulcers. Specifically, Resident #68's Skin Integrity at Risk Care Plan dated 11/15/24 and updated 2/12/25 documented to float Resident #68's heels, however it was not updated to include a new intervention when staff observed the resident moving their legs frequently when in bed.

Inspectors wroteBased on observations, record reviews and interviews during the recertification survey from 3/5/25 through 3/12/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 1 resident (Resident #29) reviewed for activities of daily living. Specifically, Resident #29 required staff assistance with personal hygiene was observed on three (3) occasions with long, stained fingernails.

Inspectors wroteBased on observation, record review, and interview during the recertification survey and abbreviated surveys (NY00347643) from 3/5/25-3/12/25, the facility did not ensure residents at risk for pressure ulcers and residents who had pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for 2 of 4 residents (Residents #68 and #352) reviewed for Pressure Ulcers. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from [DATE]-[DATE], the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for expiration dates and storage. Specifically, 1) one (1) of two (2) medication rooms examined for medication storage, had a box of expired Jevity 1.5 feeding that was stored and being used; and expired nicotine patches were stored in 1 of 3 medication carts examined for medication storage. 2) Resident #60 was found with physician ordered Isosorbide, Amlodipine, Carvedilol (blood pressure pills), Sertraline (anti-depressant), Aspirin, Apixaban (blood thinner), Folic Acid (supplement), Levetiracetam (seizure medicine), Docusate (stool softener), and Omeprazole (anti-acid) in their room on their bedside table.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, nursing staff did not perform proper hand hygiene while serving beverages at lunch meal.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, 1) the facility did not provide documentation of screening, administration, or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16) reviewed for pneumococcal vaccination; 2) there was no evidence that a Water Management Plan was reviewed and updated, if needed, annually to prevent and control Legionella; and 3) a Licensed Practical Nurse was observed putting an unsanitized blood pressure cuff into the medication cart before properly cleaning it.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16), reviewed for COVID-19 vaccinations.

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure food was prepared, stored, and served in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, 1. cooling logs were not completed for TCS (time and temperature controlled for safety) foods, 2. defrosting foods were not dated, 3. cooked TCS foods were not dated, 4. Unlabeled, undated, improperly wrapped, and/or expired foods were stored in two (2) refrigerated units; 5. TCS foods were not maintained at 41 degrees Fahrenheit (F) or less; and 6. thermometers used to monitor food temperatures were not calibrated. Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that staff followed proper hand hygiene to prevent cross contamination and the spread of infection. Specifically, 1) hand hygiene was not observed during wound treatment for 1 of 4 residents (# 16). 2) for multiple residents # 34, # 72 and # 78 during a lunch meal observation on the first-floor unit. Additionally, hand hygiene was not observed following disposal of soiled items and prior to transporting a resident (#82) off the unit.